Regarding the use of code 88387 , CPT codebook indicates that All aspects of the extended macro-scopic examination and dissection performed under sterile conditions were extensively documented. In our prac-tice, when a portion of the tissue is selected for molecular testing, we document this in the gross description as, Tissue submitted to XYZ lab for molecular analysis. Is this documentation sufficient? Or should we enhance our documentation to include the extended macroscopic exam under sterile conditions in order to better support the service rendered and assigned code 88387 ? ...
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Article Overview
This article addresses a documentation question related to CPT reporting for tissue preparation services associated with molecular testing. It is intended for coders, pathology staff, and compliance professionals who need to understand what the article says about supporting the reported service in the medical record. The discussion stays focused on CPT documentation expectations and the broad circumstances under which the service is described in the article.
Why This Topic Matters
Accurate documentation is important for aligning pathology records with the service reported for reimbursement and compliance review. This article helps readers understand the documentation focus surrounding a CPT tissue-preparation service used in connection with molecular studies.
What You Will Learn
- How the article frames documentation for tissue preparation tied to molecular testing
- What kind of record support is discussed in relation to a CPT pathology service
- Why service documentation matters in the context of reimbursement review and compliance
- The general role of the procedure record in supporting reported pathology services
Who Should Read This
- Medical coders
- Pathology billing staff
- Compliance professionals
- Laboratory administrators
- Physicians and pathologists
Codes Discussed
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